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Home My WebLink AboutApplication and WC • '� TOWN OF YARMOUTH BOARD OF HEALTH ��d��° k�� APPLICATION FOR LICENSE/PERMIT, 16 � Ut C !. L ZO 15 �. �"°' * Please complete form and attach all necessary documet�ts� �ier 1 -�015. Failure to do so will result in the return of your appli�tx�p�ake�:' " HEALTH DEPT. FSTABLISHMENT NAME• (5��JL� 1 z�a�J �-YtS i C/z�% TAX ID• LOCATION ADDRESS: q6p �'I R �N s� y�RNa u i/-f TEL.#: MAILING ADDRESS: ��n� E-MAIL ADDRESS: O 2�"i��1- ��/ t/L2S eYGA�s� • �� OWNERNAME: LE�N �' � � �/��o'v oZ°°''� CORPORATION NAME (IF APPLICABLE): ��-� �GrL p�ZlyO� / G . MANAGER'SNAME: LE O�A�4 �°t°o�3 r�cm' TEL.#: OcS'- 6Z -lo'oG2, MAILINGADDRESS: q CAi�t�Go7 �/U• l3iZEWSiE2 I /�- 02� 3 ( POOL CERTIFICATIONS: The pooi supervisor must be certified as a Pool Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. I. _ __ ___ _.— — 2 _ _ _ Pool operators must list a minimum of two employees currently certified in standard First Aid and Community Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2• 3. 4• FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years'records. You must provide new copies and maintain a file at your establishment. �. 1��,� O�r�oti z. 2�-�EccA S�„ii��' PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. ��2�G d2r'1dti,' 2. l��>'LY ��Sr�ZiKoN� ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. �LJ�LC ��21'9a �1 2. HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-chokmg procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a Cle at your place of business. �-- 1. %i�NN� G��2t�N 2. �tNNrr�-C2 �Ju�JG�" 3. Er3Bcca ER2Y 4. �nl LEW�S RESTAURANT SEATING: TOTAL# 2 3 � ---- --- _ - -_. __ AFFICEIIS�O�TLX— __ _ _ __ LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# UCENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 MOTEL $ll0 INN $55 CAMP $55 � SWIMMING POOL$110ea. LODGE $55 TRAILERPAAK $105 _WHIRLPOOL $110ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $125 CONTINENTAL $35 NON-PROFIT $30 �>100 SEATS $200 ��6 - `{ �COMMON VIC. $60 �� _WHOLESALE $SO —RESID.KITCHEN $SO RETAILSERViCE: LICENSE REQUIRED FEE PERMIT# LIC6NSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $285 VENDING-FOOD $25 =<25,000 sq.R. $I50 _FROZEN DESSERT $40 _TOBACCO $110 NAME CHANGE: $15 AMOUNT DUE = $ L�oO,Op *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** ADMINISTRATION Under Chapter 152, Section 25C,Subsection 6,the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED � OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES � NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations ofMotel or Hotel use,Transient occupancy shall be limited to the temparary and short term occupancy,ordinazily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere.Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Departrnent prior to opening. Contact the Health Department to schedule the inspection three(3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standazd plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven(7)days of closing. FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yazmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtamed at the Health Department,or from the Town's website at www.varmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter,with sample results submitted to the Health Department. Failure to do so will result in the suspension ar revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes(i.e.,outdoor seating with waiter/waitress service),must have prior approval from the Boazd of Health. OUTDOOR COOHING: Outdoor cooking,preparation,or display of any food product by a retail or food service establishment is prohibited. NOTICE: Permits run annually from January 1 to December 3 L IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S)AND REQUIRED FEE(S) BY DECEMBER 15, 2015. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY RE�Ij�A`��. / FI DATE: /Z —2 /� (� SIGNATURE: ��,�� PR1NT NAME& TITLE: M� �A GE ��Z i"l o�� Rev. 10/01/IS TNFORMATION PA�E RENEWAL AGREEI�ffiVT Insurer: I PRODUCER: Agent� 542 MA Retail Merchants WC Groug Inc. � Rogers & Gray Insurance Agency, In PO Box 559222-9222 � 434 Route 134 Sraintree, MA 02185 I South Dennis, MA 02660 (Carrier Code: 34355) i Carrier Policy ��: 014000502163116 Carrier Prior Policy ��: 0140005021b3115 1. The Insured: Oliver Ormon, I�c. Mailing Address: 6 Bray Earm Roaid Yarmouthport, I�!A 02675 j Fein: Other workplaces not shown above:� Type of Business: Corporation NO OTHER WORKPLACES FOR THIS POL�CY Risk ID: I 2. The policy period is from 12:01 a�.m. on 1/O1/2016 to 12:01 a.m. on 1/O1/2017 at the insured's ma313ng address.� � 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the state� listed here: - � I B. Employers Liability Insurancel: Part �ao of the policy applies to work in each state listed in Item 3.A. Th� limits of our liability under Part �ao are: Bodily Injurp by Accident $ 500.000 each accident Bodily Injury by Diseasei $ 500 000 policy limit Bodily Injury by Diseasel $ 500.000 each employee C. Other States Insurance: ': D. This policy includes these ent3orsements and schedules: WCOOOOOOC(O1/15) WC000310(04/84� WC000414(07/90) WC000422B(OT/15) WC200301(04/84) WC200302(OS/86) WC200303B(07/4, ) WC2003065(06/13) WC200405(06/O1) WC200601A(07/08) � i 4. The premium Por this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to vetification and change by aud;t. Classifications Code I Premivm Basis Rate Per Estimated No. � Total Estimated $100 of Annual i Annual Remunexation Remuneration Premium SEE SCf�DULE OE OPERATIOIdS ; Total Estimated Annual Premium $ � 8,938.00 Minimum Premium $ 269.00 Expense Constant .00 Deposit Premium i ii �' i il�